Intake


Intake Form
Please provide us with information about your child's family and household, health, development, education, private service (non-school), and problem behavior.
* Required
Email address *
Your email
Who referred you?
Your answer
Child First and Last Name *
Your answer
Child Date of Birth *
MM
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DD
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YYYY
Diagnoses and Date of Each Diagnosis
Your answer
Describe the concerns you have about your child's current skills and developmental history. *
Your answer
Language(s) Spoken in Household *
Your answer
Language(s) Spoken by Child *
Your answer
Child lives with: *
Address *
Your answer
Sibling Name(s) and Age(s)
Your answer
List any special needs or concerns regarding the other children living in your home.
Your answer
Parent/Guardian Name(s), Phone Number(s), and Email(s) *
Your answer
Describe any parental training or experience with ABA, special education, or pediatric therapy. *
Your answer
Please outline any family and/or household circumstances (e.g., health issues, divorce, separation, foster siblings, death, frequent travel, variable or extended work schedules, etc.) that may affect your child's progress, behavior, and/or development.
Your answer
Has your child ever been under the care of an au pair, nanny, or other long-term caregiver other than a parent or guardian? *
If yes, how many total caregivers has your child had and how long was your child under the care of each caregiver (month/year-month/year)?
Your answer
Has your child ever attended a home or center-based daycare? *
If yes, list the daycares and the time periods during which your child attended each daycare (Month/Year-Month/Year).
Your answer
Was your child adopted? *
If your child was adopted, how old was he/she when they joined your family?
Your answer
Describe any complications experienced duirng the pregnancy.
Your answer
Was the child born full term (i.e., 38-42 weeks)?
If no, what was the duration (i.e., number of weeks) of the pregnancy?
Your answer
List any operations, serious illnesses/injuries, hospitalizations, allergies, or other special conditions your child has had since birth.
Your answer
Describe any dietary restrictions or special diet your child adheres to.
Your answer
List any medications your child has taken long term (3 months or more), medications your child is currenlty taking, dosage levels, and dates medication began and was discontinued.
Your answer
How many hours of sleep does your child get each night? *
Does your child routinely sleep through the night? *
Does your child routinely take naps? *
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